This is a philosophical question. The current reality in India is that cost does decide care. Available data show that around 3 percent of the population is hospitalised annually. Around two-thirds of these hospitalisations happen in private facilities. There is a wide variety of hospital facilities available in the private sector, ranging from small places with a few facilities, through middle-level hospitals which are fairly well-equipped, to the comprehensive facilities available in some corporate hospitals. Costs also vary from relatively moderate charges in the smaller hospitals to extremely high charges in corporate hospitals. As an aside, it may be noted that high costs are inevitable when deploying highly sophisticated equipment and skills. The question really only is “who pays?” In the welfare state model, medical costs are covered by taxes in some form or the other so that most patients do not pay directly at the point of service. On the other hand, in India, despite schemes like the Pradhan Mantri Jan Aarogya Yojana (PM-JAY) the reality is that over two thirds of medical care is delivered by the private sector.
For a simple illness, it really may make no clinical difference whether one is treated in a modest nursing home or in the most elaborately equipped and staffed corporate hospital. The difference really is in the quality of the facility, what one may call the hotel segment of the hospital, probably not in the quality of medical treatment. For more complicated diseases however, especially where teams and sophisticated instrumentation is required, there certainly is a difference in the quality of medical treatment. Many interventions today, for example cancer care, require multiple specialists and expensive equipment to get the best possible results. For such treatments, ability to pay certainly determines the level of care that one can access.
The tremendous and unforeseen leaps made in medical technology has also made providing comprehensive care to every individual an expensive proposition. One of the best-known examples of comprehensive medical care, that is the National Health Service of the United Kingdom, faced with, on the one side an aging population with medical needs requiring expensive interventions, and on the other, a shortage of tax income, has taken several steps to curtail care available. Whatever is available however, is available to everyone. If a patient requires a procedure that is not an emergency (called “elective” in medical parlance), for example a knee replacement, the patient may need to wait a long time to get it. The wealthy may go to another country where private care is available. Therefore, one can argue that this is a form of rationing and costs do determine care even in countries which have socialized systems.
This is, however, a gentler form of rationing than exists in India. Here people may not be able to access dialysis for renal failure, or even a good combination of medicines required to control diabetes or hypertension. The brutal truth is that people die in India because they are too poor to pay for medical care. A study published in The Lancet (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31668-4/fulltext) estimated that 1.6 million people died due to poor quality care in India in 2016.
From the above we come to the impasse: Universal health care, free at the point of service is wonderful. Every patient getting the quality of hospital and medical care available in the NHS of the UK or better is certainly a great idea. The hitch is it costs a lot of money, and no government is willing to commit the resources required to achieve it. It is a sad fact that the Manmohan Singh government set up the High level Expert Group on Universal Healthcare under the Planning Commission in 2010 at which time Montek Singh Ahluwalia was the Deputy Chairperson, the de facto executive head. Having received the detailed recommendations (still available at https://nhm.gov.in/images/pdf/publication/Planning_Commission/rep_uhc0812.pdf) the government proceeded to completely ignore them. It is no wonder that people with no skin in the game, people who will never use it, laud the Pradhan Mantri Jan Aarogya Yojana (PM-JAY) as a game-changer. This scheme offers a coverage of Rupees 5 lakhs per family! Considering that a major illness to any member of the family will quickly wipe out this 5 lakhs, it can hardly be considered a game-changer. But that is what we have been reduced to, cheering for crumbs!
What then should a consumer group do? I would argue that it should consistently advocate for the extreme position – universal health care for every citizen. What Montek Singh gets, Munusamy should get. We should only make available in the country that which is financially possible for all. No tiered system depending on how much you can pay.
It should also participate in, and if its resources permit, initiate, all endeavours to promote science in medical care. For example, it should push for only rational drugs to be manufactured. It should speak up against the promotion of so-called Indian systems of medicine which are not scientifically verified. Speak up for science and policies for the common people. So, to return to the question, should cost determine care? The answer is, no, it should not determine care. We will get there only if we persistently fight for it.
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